Role of next generation sequencing in diagnosis and management of critically ill children with suspected monogenic disorder.

Next generation sequencing based diagnosis has emerged as a promising tool for evaluating critically ill neonates and children. However, there is limited data on its utility in developing countries. We assessed its diagnostic rate and clinical impact on management of pediatric patients with a suspected genetic disorder requiring critical care. The study was conducted at a single tertiary hospital in Northern India. We analyzed 70 children with an illness requiring intensive care and obtained a precise molecular diagnosis in 32 of 70 probands (45.3%) using diverse sequencing techniques such as clinical exome, whole exome, and whole genome. A significant change in clinical outcome was observed in 13 of 32 (40.6%) diagnosed probands with a change in medication in 11 subjects and redirection to palliative care in two subjects. Additional benefits included specific dietary management (three cases), avoidance of a major procedure (one case) and better reproductive counseling. Dramatic therapeutic responses were observed in three cases with SCN1A, SCN2A and KCNQ2-related epileptic encephalopathy. A delayed turn-around for sequencing results was perceived as a major limiting factor in the study, as rapid and ultra-rapid sequencing was not available. Achieving a precise molecular diagnosis has great utility in managing critically ill patients with suspected genetic disorders in developing countries.

Echocardiographic characteristics in neonates with septic shock.

Clinical parameters used for hemodynamic assessment and titration of vasopressor therapy in neonates with septic shock have several limitations. Functional echocardiography is an emerging tool for bedside assessment of cardiac function and may be useful for diagnosis of shock and assessing the response to therapy. Data regarding echocardiographic parameters in neonates with shock is lacking. This prospective observational study was conducted in a Level III NICU with the primary objective of comparing echocardiographic characteristics of neonates with septic shock at diagnosis, following fluid boluses, and after maximum inotropic support [A1]. Additionally, we compared these characteristics with those of healthy stable neonates who were gestation and postnatal age-matched. A total of 36 neonates with septic shock and 30 gestation and postnatal age-matched controls were enrolled. The mean (SD) gestation and birth weight of neonates with septic shock were 30.6 (4.0) weeks and 1538 (728) g, respectively. Gram-negative bacilli constituted 78.9% of all isolates. At presentation, there was no significant difference between neonates with shock and controls in terms of ventricular outputs, shortening fraction, ratio of early to late diastolic trans-mitral flow velocity, and myocardial performance indices. The distensibility index of inferior vena cava was higher in neonates with shock compared to controls, (17% vs 10%, (p < 0.01)). Left ventricular output was 209 (92) and 227 (102) ml/kg/min (p = 0.53) and right ventricular output was 427 (203) and 459 (227) ml/kg/min, (p = 0.03), respectively, before and after inotropic therapy.     Conclusion: Echocardiographic parameters may not differentiate neonates with septic shock from hemodynamically stable neonates. Neonates with shock associated with predominantly gram-negative sepsis are not able to augment cardiac functions, either at the onset or after administration of inotropes.      Trial registration: (CTRI/2017/12/010766). What is known: • For neonates with shock, echocardiography is becoming increasingly popular as an objective method of evaluating hemodynamics. • In healthy preterm neonate, cardiac output has been known to increase in response to altered hemodynamics during states of increased oxygen demand. What is new: •  In the setting of septic shock induced by gram-negative organisms, echocardiographic parameters are less likely to assist in the assessment of the response to vasoactive agents. Cytokines, induced by gram-negative organisms, may alter adrenoreceptors in myocardium and vasculature.

Effects of latent iron deficiency on auditory neural maturation during early infancy in infants above 35 weeks' gestation.

BACKGROUND: Latent iron deficiency (LID) at birth is associated with prolonged latencies in auditory brainstem response (ABR), a surrogate for neural maturation. This study aimed to compare wave and inter-peak latencies of ABR at birth and at 4-6 months of age in infants ≥35 weeks of gestation with normal iron status (NIS) and LID. METHODS: Neonates born at ≥35 weeks were screened. Cord ferritin value ≤ 75 ng/mL and >75 ng/mL were classified as LID and NIS, respectively. ABR was performed within 48 h of birth. The absolute latencies of waves I, III, and V, and inter-peak latencies I-III, III-V, and I-V were computed. Infants were reassessed at 4-6 months of age for hemoglobin, serum ferritin levels, and ABR latencies. RESULTS: In total, 160 neonates were enrolled. The mean (SD) birth weight and gestational age of the study population were 2843 (384) g and 38.3 (1.1) weeks, respectively. Approximately 122 infants completed follow-up until 4-6 months of age: 37 in the LID group and 85 in the NIS group. Overall, the wave and interpeak latencies in both groups at birth were comparable. At 4-6 months, the absolute latencies of waves I, III, and V, and inter-peak latencies I-III, III-V, and I-V were decreased and were comparable in both groups. Among small-for-gestational-age neonates, inter-peak latencies in I-III and I-V at birth were significantly longer in the LID group than in the NIS group. Nine (24.3%) infants in the LID group and none in the NIS group were iron-deficient at 4-6 months of age. CONCLUSION: There was no difference in wave or inter-peak latencies at birth and at 4-6 months of age in neonates aged ≥35 weeks with or without LID. However, infants with LID at birth have a significant risk of iron deficiency at 4-6 months of age. CTRI/2017/08/009379 (www.ctri.nic.in).

Bio-enhancement of Soy Isoflavones (Genistein & Daidzein) Using Bacillus coagulans in Letrozole Induced Polycystic Ovarian Syndrome by Regulating Endocrine Hormones in Rats.

Soy isoflavone (SIF), a natural phytoestrogen, is used in the condition of hormonal imbalance. These isoflavones generally have low solubility resulting in low bioavailability and bioactivity. It is reported that trans-glycosylation by cyclodextrin glycosyltransferase (CGTase) is widely utilized for increasing the solubility and bioavailability of isoflavones. Present investigation was aimed to study the effect of Bacillus coagulans (a probiotic) in potentiating the bioactivity of soy isoflavones in letrozole-induced PCOS. Initial consideration was focused on proving CGTase assay of B. coagulans. After that, animal study was performed to check the enhancement of bioactivity of SIF along with B. coagulans. A total of 36 rats, separated into six groups (6 rats in each), were used. Group I received vehicles, group II received letrozole (1 mg/kg) for 21 days, and group III animals were administered with soy isoflavones (SIF-100 mg/kg). In the case of group IV, V, and VI, animals received SIF (100 mg/kg) along with B. coagulans 0.65, 3.25, and 6.50 mg/kg, respectively. Treatment was given for 2 weeks after induction of disease. All the animals were sacrificed at the end of the study and endpoint parameters were performed. Present investigation revealed that combination of SIF with B. coagulans showed hormone restoration, reduce oxidative stress, recovery in the menstrual cycle, and improvement in ovarian physiology. SIF (genistein & daidzein) together with B. coagulans exhibits a beneficial role in the enhancement of the bioactivity of soy isoflavones. Further, it showed that a higher dose of B. coagulans (6.50 mg/kg) is more effective in ameliorating the PCOS symptoms.

Therapeutic Approaches to Amyotrophic Lateral Sclerosis from the Lab to the Clinic.

Amyotrophic Lateral Sclerosis (ALS) is a terminal neuro-degenerative disorder that is clinically recognized as a gradual degeneration of the upper and lower motor neurons, with an average duration of 3 to 5 years from initial of symptoms to death. The mechanisms underlying the pathogenesis and progression of the disease are multifactorial. Therefore, to find effective treatments, it is necessary to understand the heterogeneity underlying the progression of ALS. Recent developments in gene therapy have opened a new avenue to treat this condition, especially for the characterized genetic types. Gene therapy methods have been studied in various pre-clinical settings and clinical trials, and they may be a promising path for developing an effective and safe ALS cure. A growing body of evidence demonstrates abnormalities in metabolic energy at the cellular and whole-body level in animal models and people living with ALS. Using and incorporatig high-throughput "omics" methods have radically transformed our thoughts about ALS, strengthened our understanding of the disease's dynamic molecular architecture, differentiated distinct patient subtypes, and created a reasonable basis for identifying biomarkers and novel individualised treatments. Future clinical and laboratory trials would also focus on the diverse relationships between metabolism and ALS to address the issue of whether targeting poor metabolism in ALS is an effective way to change disease progression. In this review, we focus on the detailed pathogenesis of ALS and highlight principal genes, i.e., SOD1, TDP-43, C9orf72, and FUS, as well as targeted ALS therapies. An attempt is made to provide up-to-date clinical outcomes, including various biomarkers that are thought to be important players in early ALS detection.

In vitro models and ex vivo systems used in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic, relapsing gastrointestinal condition. Ulcerative colitis and Crohn's disease are types of inflammatory bowel disease. Over many decades, the disease has been a topic of study, with experts still trying to figure out its cause and pathology. Researchers have established many in vivo animal models, in vitro cell lines, and ex vivo systems to understand its cause ultimately and adequately identify a therapy. However, in vivo animal models cannot be regarded as good models for studying IBD since they cannot completely simulate the disease. Furthermore, because species differences are a crucial subject of concern, in vitro cell lines and ex vivo systems can be employed to recreate the condition properly. In vitro models serve as the starting point for biological and medical research. Ex vivo and in vitro models for replicating gut physiology have been developed. This review aims to present a clear understanding of several in vitro and ex vivo models of IBD and provide insights into their benefits and limits and their value in understanding intestinal physiology.

Amplitude integrated EEG: how much it helps in prognostication in neonatal encephalopathy?

INTRODUCTION: Neonatal encephalopathy (NE) is associated with a high risk of adverse neurological outcomes. Several neurodiagnostic tests have been evaluated to predict the prognosis. Amplitude integrated Electroencephalogram (aEEG) is now being commonly used for bedside evaluation of cerebral function. There is limited data on the role of aEEG for prognostication in NE, from resource-limited settings. OBJECTIVE: To evaluate the predictive ability of aEEG for abnormal neurological outcomes in neonatal encephalopathy or neonates with encephalopathy. METHODS: Neonates above 35 weeks of gestation admitted to NICU in a tertiary care hospital with a diagnosis of encephalopathy were enrolled. Clinical characteristics severity of encephalopathy and seizures were recorded. Amplitude integrated recording was started at admission and continued till recovery of trace to normal or for 10 days. The primary outcome was death or abnormal neurological status at 3-6 months of age. The study was registered in the Clinical Trial Registry of India (CTRI/2013/05/003612). RESULTS: The incidence of NE was 6% of total admission. Moderate and severe encephalopathy occurred in 58 and 39% of babies respectively. Hypoxic-ischemic encephalopathy was the most common cause. Clinical seizures occurred in 91% of cases. An abnormal aEEG trace was observed in 51 (76.1%) infants with NE. For adverse neurological outcomes at an age average of 4.5 months of age, aEEG had a sensitivity, specificity, NPV, and PPV of 100, 54.2, 100, and 77.5, respectively. CONCLUSIONS: Clinical staging and aEEG has good predictive ability to detect an adverse neurological outcome. aEEG improves the ability to predict abnormal outcome in babies with moderate encephalopathy. Early recovery of aEEG abnormality correlates with better neurodevelopmental outcomes.KEY MESSAGESWhat's known: aEEG is a useful modality to assess neurodevelopmental outcomes however data from developing countries is lacking.What's new: aEEG monitoring in babies in neonatal encephalopathy may improve the prediction of abnormal neurological outcomes in babies with moderate encephalopathy.

A brief review on in vivo models for Gouty Arthritis.

Gout is more common in men than in women, by a factor of 3.1-10.1. Gout prevalence and incidence have increased in recent decades, with prevalence reaching 11-13% and incidence reaching 0.4% in people over the age of 80. Age-related renal impairment, altered drug distribution, and increased prevalence of comorbidities have significant consequences for safe and effective gout pharmacotherapy. The Discovery of Fruitful in-vivo animal models needs the effective screening of drugs or formulations used in the treatment of gout. In vivo animal models of Gouty arthritis are extensively used to investigate pathogenic mechanisms governing inflammation-driven bone and cartilage damage. Four commonly utilized models include the Potassium oxonate induced hyperuricemic model, MSU crystals induced gouty arthritis animal model, Animal Model of Acute Gouty Arthritis with Hyperuricemia, and Diet-induced hyperuricemia. These offer unique advantages for correlating different aspects of gouty arthritis with human disease. In-vivo animal models served as testing beds for novel biological therapies, including cytokine blockers and small molecule inhibitors of intracellular signaling that have revolutionized gouty arthritis treatment. This review highlights a brief overview of in vivo experimental models for assessment of hypouricemic, anti-inflammatory, as well as renal protective effects of test compounds with some evaluation parameters in detail.

Restrictive Threshold for the Management of Patent Ductus Arteriosus in Very Low Birth Weight Neonates.

OBJECTIVE: To compare outcomes of very low birth weight (VLBW) neonates before and after the change in practice for treatment of PDA. METHODS: Medical records of VLBW neonates were reviewed. Neonates were categorized in two groups: Period I (January, 2012 to July, 2015) and Period II (August, 2015 to December, 2016). The primary outcome of study was composite outcome of death or broncho-pulmonary dysplasia (BPD). RESULTS: The composite outcome (Death/BPD) was comparable in two groups; adjusted OR (95% CI) 1.1 (0.6, 1.9). Mortality and severe BPD were also comparable. The pharmacological treatment for PDA was required in 8.4% vs 2.6% of VLBW neonates during Period I and II, respectively (P=0.03). Durations of invasive and noninvasive ventilation were comparable during two periods. CONCLUSIONS: Restrictive threshold for management of PDA in VLBW neonates may not be associated with increase in morbidities or mortality and possibly would reduce need for pharmacological treatment or surgical ligation.

Latent iron deficiency at birth influences auditory neural maturation in late preterm and term infants.

BACKGROUND: In utero latent iron deficiency has been associated with abnormal neurodevelopmental outcomes during childhood. Its concomitant effect on auditory neural maturation has not been well studied in late preterm and term infants. OBJECTIVE: The objective was to determine whether in utero iron status is associated with auditory neural maturation in late preterm and term infants. DESIGN: This prospective cohort study was performed at Sir Ganga Ram Hospital, New Delhi, India. Infants with a gestational age ≥34 wk were eligible unless they met the exclusion criteria: craniofacial anomalies, chromosomal disorders, hemolytic disease, multiple gestation, third-trimester maternal infection, chorioamnionitis, toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex virus infections (TORCH), Apgar score <5 at 5 min, sepsis, cord blood not collected, or auditory evaluation unable to be performed. Sixty consecutive infants with risk factors for iron deficiency, such as small for gestational age and maternal diabetes, and 30 without risk factors for iron deficiency were enrolled. Absolute wave latencies and interpeak latencies, evaluated by auditory brainstem response within 48 h after birth, were measured and compared between infants with latent iron deficiency (serum ferritin ≤75 ng/mL) and infants with normal iron status (serum ferritin >75 ng/mL) at birth. RESULTS: Twenty-three infants had latent iron deficiency. Infants with latent iron deficiency had significantly prolonged wave V latencies (7.10 ± 0.68 compared with 6.60 ± 0.66), III-V interpeak latencies (2.37 ± 0.64 compared with 2.07 ± 0.33), and I-V interpeak latencies (5.10 ± 0.57 compared with 4.72 ± 0.56) compared with infants with normal iron status (P < 0.05). This difference remained significant on regression analyses after control for confounders. No difference was noted between latencies I and III and interpeak latencies I-III. CONCLUSION: Latent iron deficiency is associated with abnormal auditory neural maturation in infants at ≥34 wk gestational age. This trial was registered at clinicaltrials.gov as NCT02503397.

Human Milk Fortification in India.

Human milk fortification in preterm babies has become a standard of care in developed countries. Use of human milk fortifier (HMF) in very-low-birthweight infants is not a routine practice in India. There are concerns about high osmolality, feed intolerance, necrotizing enterocolitis, risk of contamination and added cost associated with use of HMF. There are limited data from India which address the issue of safety and short-term benefits of human milk fortification. This chapter highlights the issues related to human milk fortification in our country.

T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT.

OBJECTIVE: To compare the duration of positive pressure ventilation (PPV) during delivery room resuscitation in neonates resuscitated with self-inflating bag (SIB) and T-piece resuscitator (TPR). DESIGN: Randomized control trial. SETTING: Delivery room and neonatal intensive care unit of a tertiary care center in northern India. PATIENTS: Consecutively born neonates more than 26 weeks of gestation requiring PPV at birth. INTERVENTION: Eligible neonates were randomized to two groups, SIB and TPR. OUTCOME MEASURES: Duration of PPV, intubation rates in delivery room, incidence of respiratory distress, need for mechanical ventilation during first 48h and its duration, need for surfactant replacement therapy and mortality during NICU stay. RESULTS: Fifty neonates received PPV with a SIB and 40 received PPV with a TPR. The mean (SD) birth weight and gestational age of neonates in SIB and TPR groups were 2264 (872) and 2065 (814)g; 35.1 (3.6) and 34.3 (3.7) weeks, respectively. The median (IQR) duration of PPV in delivery room was significantly less in TPR group as compared to SIB; 30 (30-60)s vs. 60 (30-90)s, respectively; (p<0.001). A higher proportion of neonates required delivery room intubation in SIB group as compared to TPR group (34% vs. 15%, p=0.04). In the TPR group, a higher proportion of neonates could be resuscitated with room air only (72.5% vs. 38%, p=0.001). Other outcomes were comparable in the two groups. Similar findings were observed in neonates <34 weeks, except that fewer neonates resuscitated with TPR required invasive ventilation (31.6% vs. 77.8%, p=0.008). CONCLUSION: Use of TPR during delivery room resuscitation resulted in shorter duration of PPV and lesser rates of intubation as compared to SIB. More infants in this group could be resuscitated with room air only (CTRI/2010/091/002946).

Abdominal circumference or gastric residual volume as measure of feed intolerance in VLBW infants.

BACKGROUND: The aim of the study was to compare prefeed abdominal circumference (AC) and gastric residual volume (GRV) as a measure of feed intolerance in very-low-birth-weight infants (VLBW). METHODS: Eighty VLBW infants were randomized to 2 groups; feed intolerance was monitored by measuring either GRV group or prefeed AC group. The primary outcome was time to full enteral feeds (180 mL · kg · day). Other main outcome measures were feed interruption days, duration of parenteral nutrition, incidence of culture positive sepsis, necrotizing enterocolitis, mortality, and duration of hospital stay. RESULTS: The median (interquartile range) time to achieve full feeds was 10 (9-13) versus 14 (12-17.5) days in AC and GRV groups, respectively (P < 0.001). Infants in AC group had fewer feed interruption days (0 [0-2] vs 2.0 [1, 5], P < 0.001) and shorter duration of parenteral nutrition (P < 0.001). The incidence of culture-positive sepsis in AC and GRV groups was 17.5% and 30 %, respectively (P = 0.18). Duration of hospital stay and mortality were comparable in both the groups. CONCLUSIONS: Prefeed AC as a measure of feed intolerance in VLBW infants may shorten the time taken to achieve full feeds.

Growth of very low birth-weight Indian infants during hospital stay.

OBJECTIVES: To evaluate the growth pattern of Very Low Birth Weight (VLBW) infants (birthweight <1500 g) during hospital stay and to compare the growth of Small for gestational age (SGA) and Appropriate for gestational age (AGA) infants. STUDY DESIGN: Prospective observational study. SETTING. Level III Neonatal Intensive Care Unit (NICU) in Northern India. PARTICIPANTS: A cohort of 97 VLBW infants, admitted to NICU at Sir Ganga Ram Hospital, from 1 January, 2007 to 31 July, 2008. INTERVENTION/MEASUREMENT: Weight, length and head circumference (HC) were serially measured from birth till discharge and respective Z scores were calculated as per data from Fentons references. Growth was also assessed by superimposing these trends on Ehrenkranzs postnatal growth charts. RESULTS: The mean Z scores for weight, length and HC at birth were -1.17, -1.09 and -0.54, respectively. These decreased to -2.16, -2.24 and -1.35, respectively by discharge. Both SGA and AGA infants exhibited a decrease of approximately 1 Z score in all parameters. On postnatal charts, growth of infants remained at or above respective reference lines, except in those below 1000 g at birth. Average daily weight gain after regaining birth weight was 15.18 ± 1.7 g/kg/d, whereas the increase in HC and length were 0.48 ± 0.2 cm/week and 0.60 ± 0.4 cm/week, respectively. These increments when compared to the intrauterine growth rates, indicated discrepant growth trends. CONCLUSIONS: VLBW infants suffered significant growth lag during NICU stay and exhibited disproportionately slow growth of HC and length.

Relative influence of landscape vs. local factors on plant community assembly in restored wetlands.

Ecological restoration often involves only the manipulation of abiotic factors at the local scale. However, processes external to a restoration site determine the range of local conditions within the site, constraining the level of restoration progress that can be achieved by on-site manipulations. We examined the relationship of landscape and local explanatory variables to plant species composition in 28 restored wetlands in Illinois, USA. Using constrained ordination combined with variation partitioning, we determined the independent and joint effects of three spatially hierarchical sets of variables: (1) macroscale landscape features reflecting site setting within regional landscapes, (2) mesoscale landscape features reflecting nearby propagule sources and buffers from disturbances, and (3) local environmental factors. Because the relative influence of landscape- vs. local-scale factors on restoration success may depend on particular restoration goals, we repeated the analyses using three multivariate plant community responses that represented three frequently stated goals: (1) replicating species composition, (2) restoring a particular wetland community type, and (3) constructing sites with high value for plant conservation. Explanatory variables at landscape and local scales had independent and nearly equally strong relationships to plant species composition. In contrast, when species were aggregated based on plant traits, the independent contribution of local predictors was greater than the independent contributions of macroscale or mesoscale landscape predictors, reflecting convergence of plant trait composition in sites with similar local conditions. Local predictors explained a significant amount of variation in plant conservation value among sites, but much of the variation could be explained by large-scale landscape setting, indicating that landscape constraints on local environmental conditions limited the level of floristic conservation value achievable. The appropriate scale at which to focus restoration efforts will vary depending upon restoration objectives. Restoration of particular wetland community types might be successfully achieved through manipulation of local abiotic factors. In contrast, restoration of a particular species assemblage or reconstruction of wetlands with high value for conservation requires consideration of landscape processes and available species pools.

Pneumocephalus in neonatal meningitis.

Pneumocephalus is collection of gas or air within the cranial cavity. This has been described with trauma, cranial surgery, air embolism, and rarely as a result of central nervous system infections. We report a case of diffuse pneumocephalus secondary to Enterobacter cloacae meningitis. The diagnosis was suspected by cranial ultrasound and confirmed by computer tomography.